Stigma and secrecy in Banke District, Nepal : how socieatal views are perceived to influence women's agency on accessing abortions

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Claire Thomson

Stigma and Secrecy in Banke District, Nepal

How Societal Views are Perceived to Influence Women's Agency on

Accessing Abortions

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Graduate School of Social Sciences

In partial fulfilment of the requirements of the

Masters of International Development Studies

2016-2017

Name: Claire Thomson

UVA ID: 11197870

Email: thomson.claire4@gmail.com

Date: 23 August, 2017

Word Count: 24213

Supervisor: Dr. Winny Koster

Faculty of Social and Behavioural Sciences

GPIO: Governance and Inclusive Development

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Abstract

Abortion is an essential, yet controversial, facet of comprehensive sexual and reproductive health service. Abortion is legal in Nepal, however there are still barriers to the service. Understanding of the barriers to accessing abortion services could create new pathways through which services could be made more accessible. Previous research has engaged this topic specifically from a stance of service provision, and the barriers and successes present in the services. However there is a knowledge gap surrounding non-service related facets of abortion in Nepal. This thesis examines the societal perceptions surrounding abortion in Banke District, Nepal. This research engages with both service and non-service related aspects of abortion, in order to help establish a more holistic picture of the factors that enable or discourage women from seeking abortions. This research utilised an ethnographic style, supplemented with in-depth interviews and focus groups, to reach a wide array of community youth, religious leaders, and abortion service providers. The research found that norms around gender, marriage, and childbearing were the primary sources of stigma related to abortion. There are levels of acceptability for an abortion dependent on the circumstances of the pregnancy, with marriage being the biggest condition that altered perceptions of an abortion. There were divides in abortion perceptions between Muslim and Hindu religious leaders, with Muslim religious leaders being less accepting of the procedure, however both Hindu and Muslim religious leaders acknowledge specific circumstances in which abortion can be the best option. In conclusion, there does not seem to be substantial service related barrier to abortion in Banke, rather the barriers stem from stigma against abortion in the wider community, which creates barriers for women trying to access the service. This research could contribute to future government and non-governmental organisational programme activities that engage with making sexual health services more accessible, as well as help future research in the areas of gender, stigma, and sexual health services in Nepal.

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Acknowledgements

There are many individuals and organisations that I would like to thank for making this research possible. Foremost, I would like to thank my thesis supervisor, Dr. Winny Koster from the University of Amsterdam, who has spent many hours working with me to help develop my research, and has supported me throughout my data collection and writing process. The many hours she has dedicated to editing and guiding my writing has been invaluable, and it is fair to say that her knowledge and support have ensured the completion of this thesis with my sanity intact.

I would also like to give special thanks my field supervisor, Dr. Anand Tamang from the Center for Research on Environment Health and Population Activities (CREHPA), for his insight into the specific context of Nepal. His help win understanding the local context helped me to both design and conduct my research effectively. Additionally, the many individuals and organisations he was able to connect me with ensured that I was able to gather a wide range of data and conduct my fieldwork effectively. Without his help, my field work would have been much less successful.

I would like to give another special thanks to the two other master's students from the University of Amsterdam who were conducting research within the Her Choice Project in Nepalgunj as well, Mr. Rory Bowe and Ms. Kianna Dewart. Through coordination of our research activities I was able to gather a much wider and more diverse range of data than I would have achieved on my own.

Another special thanks to Gerylaine Campos, a fellow student whose support in both writing and editing kept my work on track, and ensured a strong final result. Much of my flow and cogency is a result of her assistance.

Finally, I would like to thank all the individuals, organisations, and institutions in both Kathmandu and Nepalgunj that made my research a successful and rewarding experience. My research participants repeatedly shared their insights and thoughts with me, and often went above and beyond to provide me with data that I needed, whether it was statistical data, or informal studies conducted by their organisations. Special thanks goes to the staff at Child Workers in Nepal (CWIN) for opening their doors to me and helping to connect me with many different organisations and institutions that were crucial to my research. I would like to thank CWIN for all the time and patience their staff showed in helping me adjust to cultural differences and navigating the nuances of Nepalgunj society. Another special thanks to CREHPA for the many connections they provided me in Nepalgunj, and in particular the Muslim Community Development Learning Center of Nepal, who provide insurmountable help by facilitating and accompanying me to visit rural health posts, allowing me to quickly establish the trust

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needed to conduct my research in these rural communities. For all the invaluable help, as well as making me feel welcome and safe, I express my sincerest thanks.

Claire Thomson

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List of Figures

Figure 1: Conceptual Scheme...25

Figure 2: Location of Banke District in Nepal ...28

Figure 3: Map of Banke District, Nepal...28

Figure 4: Buildings in Nepalgunj...29

Box 1: Shree Secondary School...32

Figure 5: Shree Secondary School, Nepalgunj...32

Figure 6: CWIN Girls Empowerment Group. Run Daily in Lagdhwa Community...34

Box 2: Personal Reflection on Research...39

Box 3: Madhesi Marriage Practices...44

Figure 7: Number of Children a Woman has had at Time of Abortion, Made from 92 Medical Records from the Safe Abortion Books in Hirmaniya and Raniyapur...49

Figure 8: Cartoon Drawn by Five Girls, aged 13-15, in a FGD at Shree Secondary School...56

Box 4: A Rural VDC Health Post...58

Figure 9: Poster in Raniyapur Healthpost with a Checklist for Safe Medical Abortion ...59

Figure 10: Poster in Udherephur Health Post Displaying and Explaining Various Options for Contraception...59

Figure 11: Revised Conceptual Scheme...67

List of Tables

Table 1: Data Gathering and Participant Demographics...36

Table 2: General Data from Safe Abortion Books in Hirmaniya and Raniyapur VDC's...37

Table 3: In-Depth Interviews with Girls...77

Table 4: Interviews with Married Boys...77

Table 5: Focus Group Discussions with Men and Boys...78

Table 6: Focus Group Discussions with Girls...78

Table 7: Interview with Health Workers...79

Table 8: Interviews with Religious Leaders...80

Table 9: Informal Conversations Informants...81

Table 10: Informal Conversations and Observations...81

Table 11: Number of Existing Children Birthed by Women in the Safe Abortion Books of Hirmaniya and Raniyapur...82

Table 12: Age of Women at Time of Abortion...82

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List of Acronyms

CWIN: Child Workers in Nepal

CREHPA: Center for Research on Environment Health and Population Activities D&C: Dilation and Curettage (abortion method)

DHS: Demographic Health Survey FGD: Focus Group Discussion

IUD: Inter-Uterine Device (birth control method) MVA: Manual Vacuum Aspiration (abortion method) NGO: Non-Governmental Organisation

SRH: Sexual and Reproductive Health

SRHR: Sexual and Reproductive Health and Rights UN: United Nations

VDC: Village Development Community WHO: World Health Organisation

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Chapter 1: Introduction

This thesis is based on the findings of a study on the factors that enable and restrain accessibility to abortion services in Banke District, Nepal. Sexual and reproductive health (SRH) services are an essential aspect of healthcare for both individuals and communities. However, despite their importance, these services are often considered controversial and face substantial opposition in both their existence and their accessibility. One of the most controversial SRH services is abortion (Finer and Fine, 2013). Globally, 32 countries have laws that do not permit abortion for any reason, 59 countries only allow for abortion to save a woman's life or preserve her health, and 56 countries allow abortion without a reason (although most have various restrictions of the gestation period limit during which an abortion can be preformed) (Myers and Seif, 2010). There has been ample research that has shown how a lack of access to safe abortion services results in higher maternal mortality, as women will still attempt an abortion regardless of legality, and thus be forced to seek out illegal and unsafe methods to terminate their unwanted pregnancies (Kapp and Glasier, 2013). Approximate yearly deaths from unsafe abortions are 47000 globally, while an additional 5 million women are left disabled in some way from an unsafe abortion procedure (Ibid).

In an attempt to mitigate the challenging reality of abortion access, a multitude of organisations advocate for safe and accessible abortion services globally. One such organisation is the International Federation of Gynecology and Obstetrics, which works globally to ensure that every woman has access to safe, effective, and affordable SRH services, including comprehensive and safe abortion care (Myers and Seif, 2010). While there are substantial movements in development to help ensure that SRH services, including abortion, are accessible, these movements face frequent opposition from pro-life organisations, and multiple legal challenges. The United State President Trump's recent reinstatement of the Mexico City Policy (also known as the Global Gag Rule) on January 23, 2017, is one of these challenges faced internationally, since it bars organisations who support or provide abortions from receiving any funding from the United States Government (Office of the Press Secretary, 2017).

Nepal is one of the countries where abortion is legal, with certain restrictions, since 2002. In Nepal, abortion was criminalized in the Country Code of 1854 upon religious Hindu grounds (Upreti, 2014). This law was clarified in 1963, with the ban remaining, but clarifying that there would be no criminal liability for an abortion performed as an act of benevolence (Ibid). However this offered no practical path for women as the definition of benevolence was never clarified (Ibid). There is ample evidence showing that this ban was detrimental to overall population health, with women resorting to

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unsafe, sometimes deadly, means to acquire abortions through illegal channels (Ibid). Strong efforts by medical professionals, public health organisations, and women's right groups throughout the 1990's caused the Nepalese Government to legalize abortion, albeit with some restrictions, in 2002 (Ibid). The 2002 law allowed a woman to obtain an abortion for any reason within the first 12 weeks of pregnancy, within 18 weeks if the pregnancy was a result of rape or incest, and at any time during the pregnancy if it poses a risk to a woman's life or health (physical or mental) or if the fetus is impaired (Ibid). Women under the age of 16 require parental consent to obtain an abortion, and no abortion may be legally performed without the consent of the woman, however the fetus's father's consent is not required (Ibid). The law does not allow for sex-selective abortions or abortions performed without the woman's permission (Population Division, Government of Nepal, 2012). The Government of Nepal has made strong efforts to ensure that abortion is accessible to the population, recently providing funding in the 2017 Federal Budget to ensure that all abortions done at government facilities are fully funded (Ipas: Health, Access Rights, 2016). However, even with strong government initiatives to ensure the accessibility of abortion, there can still be a multitude of barriers for women to access the procedure (Myers and Seif, 2010).

Abortion is a contentious topic both in government policy and in many community beliefs, so it is important to understand how these various factors impact the practical accessibility of abortion. Even in countries in which laws allow for various medical procedures and motivations for abortion, such as Nepal, the legal permissibly does not necessarily translate into accessible services or practices. There can still be a multitude of social or service barriers to access abortion. It is important for research to engage with abortion accessibility so as to determine what factors are preventing laws from being implemented and the services they provide from being used. Determining whether this disconnect with law and access exists or not, and if so, whether the causes are mainly community factors surrounding perceptions of abortion or directly service related factors, the knowledge can enable action. By understanding the factors that prevent the provision of safe abortion services to a community, various government and non-governmental organisations (NGO's) can adapt their programmes accordingly to fill the gaps between law and practice. The objective of this study was to contribute to closing this knowledge gap by engaging with the various factors that either enable or discourage women from seeking an abortion in Nepal, focusing on Banke District in the Mid-Western Terai region. This connects closely with broader themes in development and gender, engaging with accessible SRHR and gender norms, and contributes to a larger body of literature focusing on these issues. This study will

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allow local organisations to expand their planning and address access barriers and so contribute to making abortion services more accessible.

1.1 Outline of the Thesis

This thesis provides a full examination of existing literature surrounding abortion (as well as various influencing factors surrounding abortion) in Nepal, in Chapter 2. Then, in Chapter 3, the key theoretical concepts found within the literature are fleshed out into a full theoretical framework to allow for a complex and nuanced understanding of the findings and ensure that they are connected to existing theory. An explanation of the research design, including the research location, research questions, methods used, ethical considerations, and methodological limitations, is provided in Chapter 4. Chapters 5 through 7 provide the empirical results to the three sub-questions in turn, engaging with gender, marriage, and childbearing, community perceptions of abortion based on the conditions of the pregnancy, and local abortion services. Chapter 8 then connects these themes found in the empirical chapters to provide an answer to the primary research question. Finally, the conclusion, Chapter 9, restates the central findings, and provides recommendations directed at local government and NGO's to adopt into their programmes, as well as areas of future research.

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Chapter 2: Research Context

This chapter engages with the existing literature around abortion in Nepal and with important themes and norms that are related to abortion acceptability and accessibility. Specifically, this chapter engages with the current state of abortion in Nepal, building on the previous introduction in Chapter 1. Afterwards, literature surrounding abortion service provision is examined, before an examination of literature surrounding gender and childbearing norms (and expected roles) in Nepal. Finally, Hindu and Islamic (the two major religions in Banke) theology surrounding abortion is examined in depth.

2.1 Abortion in Nepal

Despite the legality of abortion in Nepal since 2002, it was not until 2004 that the Nepalese Government began providing comprehensive abortion services (Population Division, Government of Nepal, 2011). As of 2010, there are 245 registered abortion sites that cover all 75 districts of Nepal (Ibid). Abortions in Nepal can be legally provided through surgical or medical methods. Surgical abortion, mostly manual vacuum aspiration (MVA), must be provided by a registered medical professional, such as a trained doctor or nurse at a clinic or hospital. Medical abortion is done through use of Mifepristone and Misoprostol pills, and can be provided through either registered clinics and health posts, or through clinic's outreach health workers (Möller et al., 2012). Medical abortion has become more common as it requires less control by health care providers and allows greater access to abortion in rural areas where health care facilities capable of performing surgical procedures are further apart (Padmadas, Lyons-Amos, and Thapa, 2014).Health workers can give accurate information on the usage of Mifepristone and Misoprostol in the termination of early pregnancies up to 9 weeks (or 63 days) from conception (Tamang et al., 2015). In addition to health workers, research on Mifepristone and Misoprostol provision by Tamang et al. (2015) found that pharmacists in Nepal can also safely provide and counsel use of these drugs. However they found that pharmacists have knowledge gaps surrounding follow up with patients in order to ensure the abortion was completed and no complications occurred, and thus still require additional training regarding abortion completion and other follow up concerns (Tamang et al., 2015).

Knowledge and practice of abortion is varied among women in Nepal. The Nepal Demographic Health Survey of 2011 found that 38% of women of childbearing age (here classified as 15-49), knew that abortion is legal in Nepal (Population Division, Government of Nepal, 2012). Fifty-nine percent of childbearing aged women reported knowing where to obtain a safe abortion, with higher knowledge of

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the government sector provided abortions as opposed to private providers (Ibid). The most knowledgeable regions for where to obtain a safe abortion are the Western and Mid-Western Terai (in which Banke is located), with 73% and 71.2% respectively (Ibid). The least knowledgeable region is the Western Hill region, with only 39% of women reportedly knowing where to obtain a safe abortion (Ibid). In Nepal, from 2005-2010, 8% of pregnancies were aborted, with the majority of those abortions occurring in urban areas, with 8% of women who had an abortion crossing the border to India for the procedure (Ibid).

Although service related factors (both enabling and restricting) are important for women seeking abortions to consider (discussed below), societal related influences are also important influences to consider. There a variety of possible motivations for women to abort, and the differences between these various motivations can influence the societal factors (both enabling and restricting) that she will have to consider. According to the 2011 Demographic Health Survey, the most common reasons that women gave for terminating their pregnancy were that they did not want more children, their partner did not want the child, to space the births of their children, to delay childbearing, health reasons, or that they lacked the money to care for the child (Ibid). A study by Puri et al. (2007) found in a survey of 997 married women between the ages of 15-24 that 49% of these women had experienced an unintended pregnancy, of which 26% had considered abortion as a solution. Of the 26%, roughly half of these women attempted an abortion, however only a third were successful in their attempt (Ibid). Puri et. al. (2007), found that in their study the reason's women gave for continuing an unintended pregnancy were that to abort would be a sin, opposition by husband or family members, and fear of consequences if their community found that they had had an abortion.

2.2 Abortion Service Provision

The literature surrounding abortion provision in Nepal engages broadly with service related barriers to abortion. During research in the Kathmandu Valley on sexual behaviour and knowledge among youth, Tamang (2015) found that respondents expressed concerns about the privacy of abortion facilities, but still perceived hospitals and health clinics to be the safest places to obtain an abortion (medical or surgical). As it is illegal for a woman under 16 to have an abortion without parental consent, that could potentially be a significant barrier for women under the age of 16. This could cause them not to seek out official hospital or health clinic services, but instead seek out illegal abortion services in secret. Möller et al.'s (2015) study interviewed 15 doctors and nurses who preformed abortions in the

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Kathmandu Valley regarding the perceptions that they had towards their roles. Their study found that health workers perceived that the high cost (the average cost of having an abortion in Nepal is roughly 8-30 Euros), lack of access to services in rural areas, and too few providers, are all significant barriers to abortion access (Möller et al., 2015).

2.3 Gender and Childbearing Norms

Broader norms of gender and childbearing are instrumental to understanding societal perceptions of abortion services, as abortion is a gendered service that infringes on these norms.

Nepal is a patrilineal and patriarchal society, with family lines continuing from the male side, and men given a higher social standing than women (Mattebo et al., 2016). Deriving from the strictly partilinial nature of Nepali society, there are rigid gender roles that permeate Nepali society. In her thesis on gender roles and stereotypes for women in Nepal, Bhandari (2013) found that women in Nepal are expected to conform to a wide array of gendered roles and expectations, and that these gender roles are created through opposition to the roles expected of men. Luitel's (2011) work on the social roles of Nepalese women provides an in depth examination into how women's roles in their families represent their broader roles and status within society. Luitel (2011) goes on to show how these roles change throughout a woman's life, but always in relation to the men in her life. She found that women have very little control over their family choices, with their parents arranging their marriage, and then their mother in law controlling many of her decisions (Ibid).

One of the ways gender roles are clearly seen in Nepal is through marriage. During marriage, the woman's family is expected to pay a dowry to the mans family, either in the form of money or material possessions. Lundgren et al. (2013) found women are encouraged to marry early in order to reduce dowry price, as well as that their families believe it is more important to invest in their daughters dowry than her education. The 2011 Nepalese Demographic Health Survey found that the median age that women were married by in the Mid-Western Terai was 17.5, (legal age of marriage in Nepal is 20) whereas the median for men was 20.1 (Population Division, Government of Nepal, 2012). Women are considered responsible for maintenance of a household, which begins with girls being burdened by housework at a young age, and continues throughout their lives (Luitel, 2011). Men are considered the breadwinners of the family and are encouraged to work outside of the home, whereas women are pressured to stay at home and care for the family, often to the neglect of her own income earning possibilities or education (Ibid). As these are the assumed roles for women, girls education is

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often not highly valued. This leads to higher dropout rates from school for girls than for boys, as it is believed that they will not need their education given their presumed future roles in the home, and are preferred to be kept at home doing chores (Parker et al., 2014).

Gender norms and roles in Nepalese society are clearly viewed through the various norms around childbearing. Regmi et al. (2011) examined sex and sexuality in Nepal, and found that sexuality outside of the confines of marriage is considered unacceptable for both men and women, and pre-marital sex is considered taboo. While this is the dominant narrative, Regmi et al. (2011) did find that these norms were shifting to include more openness to dating and pre-marital sex among adolescents in Nepal, however not within broader society. Within marriage, sex is encouraged to birth children, as that is considered one of the primary roles of married women (Upreti, 2014). This role is so central that a study by Bhandari et al. (2008) specifically found that stigma surrounding abortion in Nepal stems from the challenge that abortion provides to gender roles of Nepalese society, specifically the challenge to the perception that it is a woman's role to bear many children.

Having many children is a traditionally prized norm in Nepal. According to the 2011 Nepalese Demographic Health Survey (DHS), the average fertility rate for a woman in the Mid-Western Terai region is 3.2 children, the highest in the country (Population Division, Government of Nepal, 2012). Daughters are perceived as a burden with little return, as they will leave the home and require a dowry when they are married. By contrast, sons increase the status of the woman within her family, as sons stay with their parents and help provide for them in their old age (Bhandari, 2013). In addition, Hindu theology places a higher value on sons, as they are the ones who will perform the funeral rites for their parents when they die (Brunson, 2010). Traditionally, large families are valued in Nepal, however Brunson (2010), in her research into the changing norms of kinship and fertility in Nepal, found that Nepali's have an increasing desire for a small family size. This is demonstrated in preliminary results from Nepal's 2016 DHS, which show Nepal's fertility (region specific numbers have not yet been released) as 2.3 children per woman, in comparison to 4.6 children in 1996 (Ministry of Health, et. al , 2017, Page 13). Brunson (2010) found that the pressure to birth sons is contradicting these newer values, as couples will continue to have children, regardless of the number, until they are able to birth a son. For women, children help to solidify a woman's place in her in-laws family, however her position is not fully secure until she gives birth to a son (Luitel, 2011).

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2.4 Hindu and Islamic Theology Related to Abortion

Hinduism and Islam are the two major religions in Banke, and both are prevalent facets of social life. As such, it is important examine their stances on abortion, as the influential nature of the religions could impact the perceptions of community members.

Hinduism is a fluid religion that prioritizes pluralism and focuses on the individual fulfilling their obligations to themselves, their family, and society, as opposed to focusing on a specific set of rules for worship of deities (Pinter et al., 2016). Pinter et al. (2016) explain in their article examining various religions stance towards family planning, that Hinduism has a positive view of sex, teaching that it is meant to be enjoyed by both parties within the confines of marriage. Hinduism does not have any specific rules regarding contraception, however life is considered to begin at the moment of conception, thus making abortion unacceptable (Ibid). However, even though it is perceived as the ending of a life, Hinduism is a flexible religion and allows abortion in certain situations (Pinter et al., 2016). Hinduism permits abortion in cases where the individuals involved deem it to be the most moral pathway, following the Hindu principal of least harm in cases where continuing the pregnancy would result in greater harm to the woman and the family than abortion (Ibid). However, in his comparative study on abortion attitudes between religions, Jelen (2014) found that Hindus were more likely to condemn abortion based on other Hindu values, such as gender norms. So although theologically abortion may be permissible to Hindus, other Hindu values demonstrate opposition to the procedure.

Islam is the other major religion in Banke, and has varied views on abortion. Islam is a diverse religion, and that takes different forms in different locations, due to rules that allow various Mullahs (an Islamic religious leader who has learned Islamic theology and religious law) to interpret the Quran (Pinter et al., 2016). Jelen's (2014) comparative study found that Muslims were the least likely of all major religions to regard an abortion as justified, and found that this opposition stemmed from both the desire to preserve life and to preserve sexual morality in the religion, as abortion was perceived to encourage extra-marital relations. Specific interpretations of abortion are varied among Muslims across the world, although the Quran puts the health of the mother before the health of the child, meaning that if the health of the mother is compromised then an abortion would be permissible (Ibid). Islam also teaches that couples are not allowed to limit the number of children they have, but that birth spacing as to ensure the health of mother and existing child is important (Ibid). This means that an abortion as a means to space births in order to ensure the health of the existing child is permissible, whereas an abortion so as to stop bearing children is not (Ibid).

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Chapter 3: Theoretical Framework

This research engages with several significant theoretical concepts, which have been drawn from the themes of the literature examined in Chapter 2: gender, stigma, agency, and accessibility of health services. The literature on abortion discussed influential gender roles that effect almost every aspect of life in Nepal, and are thus central to understanding broader conceptions of stigma, agency, and accessible health services. Stigma as a theoretical concept is utilised due to the societal opposition to abortion found in the literature, which often gives rise to stigma. Agency is included as, given the assertions in the literature that women do not have extensive control over their own lives, it is important to examine their agency to make their own SRH decisions. Finally, accessibility of health services is explored, as the services themselves play a substantial role in the accessibility of a health procedure. The theoretical backing to these various concepts are examined in depth in this chapter, before providing an explanation of how the various theories interact in the research and providing the conceptual scheme that illustrates this interaction. Finally, the questions for this research are developed and provided.

3.1 Gender

For the purposes of this research, gender is used in reference to Riseman's (2004) definition, as a socially constructed institution that ascribes norms and roles based on sex, as opposed to an inherent set of traits to an individual. Gender roles are a central facet of most societies, and they manifest differently dependent upon context. It is the specific context that defines the specific gender roles that an individual will be required to uphold. Gender roles thus defy any definition that attempts to divide them by specific roles for men and women, but rather need to be determined by the factors that allow for that division to occur. Manago et al. (2014) argue that gender roles arise through the values held by the society, and that these values change depending on the level of industrialisation of a society. The authors argue that in largely agrarian societies gender roles are more rigid and centre around particular values of family and continuing the family unit, and thus are developed on controlling sexuality (given the central nature it plays in procreation and thus expansion of family units) (Ibid). This is because divided roles ensure a smooth functioning of a whole family unit, ensuring that men and women have separate tasks to create a complementary set of skills (Ibid). By contrast, the authors argue that as societies industrialise, the centrally held values shift to become more individualistic (Ibid). This shift centres more around concepts of choice and equality, making for less rigidly defined gender roles and

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allowing for greater freedoms of sexuality and expression (Ibid). This argument is supported by similar work done by Hansen et al. (2015) on how agrarian societies tend to have more rigid gender roles that have a more central role in daily life. The work of Manago et al. (2014) is significant in the context of Nepal, in which family is the central unit and the society is largely agrarian. In this context, the argument that Manago et al. (2014) make, of family being the crucial unit through which gender roles are created, is significant, as gender roles themselves can not be seen to be created around the individual, but rather through the family groups that compose the broader society.

While Manago et al. (2014) provide a solid explanation of how gender roles themselves arise, the way that these gender roles manifest is often unequal and dis-empowering, in nature. Gender inequality is a significant issue globally, in which the genders are treated differently, with the effect of creating unequal access to services, decision making power, agency, and various opportunities throughout an individuals life. Risman (2004) engages with gender inequality by arguing that the ways in which gender roles are produced often creates a strong level of gender inequality in society. She argues that this is due to that gender roles are often divided based on status, and that subsequently prevents individuals deviating from their ascribed roles (Ibid). Risman (2004) argues that gender roles are expected to be followed in society and have been given a variety of values based upon the gender that the role is assigned to, with typically male roles generally receiving higher social status than typical female roles. Risman's (2004) argument thus concludes that women, in being assumed to take responsibility for typically lower status roles in society, are often perceived as themselves being lower status given their roles, and that men have a substantial amount of power to gain by continuing this perception, thus contributing to gender inequality.

Gender inequality is a particularly salient issue, as it contributes to creating barriers to abortion access for women. In response to gender inequality, a multitude of development projects have been focused on ending gender inequality globally, specifically targeting at empowerment programmes at women and girls. These programmes include both the UN's 2000 Millennium Development Goals and the 2015 Sustainable Development Goals, which both have explicit targets for ending gender inequality globally (United Nations, 2000, and 2015). However, gender and development has not changed from fundamentally only addressing women in development programmes. In response to this, there is a rising body of theoretical literature opposing how this change in language has not led to a change in policy, and is advocating for the inclusion of men in the process of creating gender equality. Wanner and Wadham (2015) propound the argument that it is essential to include men in programmes that work

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to create gender equality in order to ensure their success. They argue that while there has been a slow push in the recognition of the need to involve men in recent years, this has not been accompanied by any direct action (Ibid). Part of the reason for this exclusion has been that the societal dividends gained by men from their position of power make many men reluctant to yield their privileged position (Ibid). In addition, the challenges of including men without undermining the goal of women's equality and empowerment have been substantial (Ibid). The authors argue that there should be greater efforts to include men in programmes focused on gender equality and female empowerment, because men (as more privileged) are often the gatekeepers of values and have the potential to be the instruments of change (Ibid). In addition, they recognize that men gain from gender equality, as patriarchal norms also prevent them from deviating from their prescribed roles (Ibid). This argument is furthered by Yeboah et al.'s (2015) engagement with men in development, in which they argue that by excluding men from development programmes organisations fail to tackle the root causes of gender inequality in society, only focusing on the effects.

3.2 Stigma

Stigma is a common and flexible term within social sciences research, and has a variety of definitions that are used in a broad range of circumstances over a variety of different disciplines. Link and Phelan (2001) examine this multitude of definitions before providing a definition of their own. They show how the literature has referred to stigma as a type of stereotyping, rejection by a community, a mark of disgrace upon an individual, or as a response to an individual who is perceived to have an attribute or characteristic that runs in opposition to the communally held norm (Ibid). The authors propound that there have been multiple issues with the existing approach to stigma, in particular that it is often studied by researchers who do not themselves experience stigma, and that the literature tends to be highly individualistic in nature, focusing on individual experiences as opposed to relationships and structural stigma (Ibid). The definition of stigma that they propose is a multilevel approach to stigma. They define stigma as the convergence of multiple components:

“In the first component, people distinguish and label human differences. In the second, dominant cultural beliefs link labeled persons to undesirable characteristics—to negative stereotypes. In the third, labeled persons are placed in distinct categories so as to accomplish some degree of separation of “us” from “them.” In the fourth, labeled persons experience status loss and discrimination that lead to unequal outcomes. Finally, stigmatization is entirely contingent on access to social, economic, and political power that allows the identification of differentness, the construction of stereotypes, the

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separation of labeled persons into distinct categories, and the full execution of disapproval, rejection, exclusion, and discrimination”. (Ibid, Page 367)

This multilevel definition provides an encompassing view of the complexities of the various definitions of stigma, however, for the purposes of this research it is still too broad.

Link and Phelan (2001) provide a good starting point from which to understand the various complexities of stigma, however their definition is not specific enough to be directly applicable to this research. Instead, the definition of stigma that will be applied for the purposes of this research is provided by Kumar et al. (2009), on the roots of stigma surrounding abortion. Kumar et al. (2009 defines abortion stigma as “...as a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood” (Page 628). The authors elaborate that abortion is particularly stigmatized because of its contradiction to norms surrounding motherhood, family, female sexuality, and female agency (Ibid). Abortion, by contradicting these norms, is perceived to be an act of women rebelling against gender roles in a way that is deeply upsetting to society (Ibid). In addition, the authors argue that a women's use of agency to seek an abortion can often be seen as deeply problematic, as she is perceived not to have the right to make life or death decisions (in regards to perceptions surrounding the fetus) (Ibid). However, in a cautionary critique of her earlier 2009 work cited above on abortion stigma, Kumar (2013) argues that it is important not to allow stigma surrounding abortion dominate the debate. She cautions to remember that stigma exists on a larger and broader scale and is intertwined with many more social inequalities, and to limit research only to how stigma relates to abortion will yield a narrow and uninformed view (Ibid).

In addition to stigma specifically concerning the woman seeking an abortion, it is also important to engage with stigma by association. Stigma by association is, as defined by Neuberg et. al (1994), as occurring when "...in which a normal individual is stigmatized by others as a function of his or her association with a marked [stigmatized] individual or group." (Page 197). Neuberg et. al (1994) specifically argue that stigma by association will arise out of a type of balance of values in order to preserve those values which an individual feels most strongly. When a person with the attribute that gives reason for stigmatisation associates with a person that does not have that attribute, a third party must conclude as to whom the stigma belongs. This is based upon whether the third party feels more strongly invested in preserving their perception of stigma, thus stigmatizing the associating individual, or their perception of normal, thus de-stigmatizing the stigmatized individual. The third party will then

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side with whichever they feel most strongly towards (Neuberg et. al, 1994). Stigma by association has been extensively engaged with surrounding stigma arising from HIV (Mason, et. al, 2010), as well as mental illness (van der Sanden, et. al, 2014). Through stigma by association, it is possible that the family members, or associates, of a woman stigmatized for abortion could also be stigmatized. This could have a broader effect on abortion stigma in Banke, and should be kept in consideration.

3.3 Agency

The third major theoretical concept is agency. Kockelman (2007) identifies several key ways in which agency is categorized. First, he describes agency as a drive for hope or rebellion, a means of resistance or reactance, and as a mediating rationality, best explained as “... having no choice about the field of options within which one may freely choose” (Page 376), all of which combine ideas of flexibility and accountability (Ibid). Kockelman (2007) describes agency as a word that is synonymous with knowledge and power. As agency is used in a variety of manners to clarify a broad range of behaviours it is hard to find an exact definition, instead Kockelman's (2007) classification can be broadly applied to most circumstances. However, this definition requires expansion in order to encompass how factors such as gender or class effect the ability for one to express their agency in any given situation. In their article on expressions of agency exhibited by young women in regards to their sexual lives at an English private school, Maxwell and Aggleton (2009) argue that agency must be conceptualized, and while there is always a possibility to extend agency in any circumstance, social class must be understood to be a mediating factor. The authors found that young women expressed their agency in their sexual lives only after dissecting and understanding the division of power within their relationships, and that they would extend their agency in a varied ways in relation to the this power dynamic (Ibid). In this article, the combined understandings of accountability, flexibility, and power from Kockelman's (2007) definition can be found in practice with the mediating factors of the specific social context.

In the context of women in Nepal, the existing literature surrounding women's agency is particularly concerned with the increase and changes in agency with the rise in modernisation and access to new sources of information. One such argument is made by Ahearn (2004) in her examination of the effect that literacy is having on women's agency, particularly in regards to norms and practices surrounding love, marriage, and courtship. Ahearn (2004) posits that education and literacy are not neutral forces, and that the effects that increased literacy have on expressions of agency within a

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society are dependent on the existing societal norms of that society. In the context of Junigau, Nepal, the increased literacy did result in an increase of agency in some situations (Ibid). In particular, the increased literacy provided young people with new avenues of agency for changing the norms surrounding dating and marriage, resulting in an increase in elopement and a decrease in capture and arranged marriages (Ibid). However, Ahearn (2004) also shows how the new opportunities for women to act with agency in their romantic lives came at the cost of a loss of potential agency in the future. This decrease came from that if they eloped they lost the support of their natal family, and could be left with little help, support, or choices, should they experience struggles with their husbands at home or become separated from their partners (Ibid). So while literacy brought new avenues of agency for women, it did so at the expense of extinguishing previous ones in the process.

Kumar et al. (2009), argue that, in regards to abortion, agency is often limited by “...systems of unequal access to power and resources, narrow and rigid gender roles and systematic attempts to control female sexuality” (Page, 628), and that women often have to exercise considerable agency in defiance of cultural norms in order to access an abortion. This expression of agency is consistent with the definition of agency as a form of rebellion or resistance, such as what is posed by Kockelman (2007). However Kumar et al. (2009) are clear in the link that they demonstrate between use of this agency to defy community norms and how the agency used by these women can lead to experiences of stigma by the community. In their article on factors influencing young couple's decision to abort, Puri et al. (2007), found that in most situations the final decision whether or not to abort was made by a woman's husband, and in situations where the woman made the final decision it was often as an expression of agency in order to avoid upsetting or angering her husband, and thus preserve her own position in the family. Puri et al's study clearly demonstrates the importance of context to agency and the decision making process, as women's use of agency was influenced strongly by their husbands and the values of their community (Ibid). In regards to women's agency surrounding abortion in Nepal, understanding the cultural context is crucial to understanding the limitations that surround the ways in which women can utilise their agency, and it is similarly important to understand how stigma both shapes their use of agency, and can effect women as a result of their exercise of agency.

3.4 Accessible Health Services

The final concept that will be examined is accessibility of health services. Access to quality health care is a fundamental human right under the UN's Universal Declaration of Human Rights (1948), and there

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is a wide array of literature that focuses on the factors that make a health service accessible. Various contexts require different approaches to ensure quality care. For example, Farmer et al. (2011) examine the specific challenges in providing accessible health care to rural citizens in Scotland. In their article the authors show the specific challenges of a government trying to ensure that all citizens have access to quality health care, while working within a resource scarce environment (Ibid). However, in contrast to a developed country such as Scotland, Dejardin (1994) argues the health care challenges are substantially different in developing countries. Dejardin (1994) argues that the health problems that concern citizens of developed countries can be focused more on the nuanced ethics of health provision, but that in developing countries the focus surrounds ensuring that a majority of the population have access to health services. He argues that quality health care in developing countries will be achieved through the provision of more efficient health care, better managed health services, improved geographical accessibility, and improving health care acceptability (Ibid). The World Health Organization (WHO) builds on Dejardin's (1994) criteria for quality health care, which it defines as being effective, efficient, accessible, acceptable/patient centred, equitable, and safe (World Health Organization, 2006). They emphasize that there is a need for multiple levels of government and policy to engage with the whole health system in order to facilitate quality health care, and that quality service is achieved through coordination and cooperation of both health service providers and communities of service users (Ibid).

The WHO provides a more comprehensive approach to what enables quality health care in a developing context. The WHO provides six dimensions of quality that health services must respond to: effective, efficient, accessible, acceptable/patient-centred, equitable, and safe (World Health Organization, 2006). These indicators will be dealt with in turn. The WHO (2006) explains that effective care is health care that responds to an evidence base which improves health outcomes based on the needs of the community. Efficient care refers to health care which maximizes resource usage, and accessible refers to care that is appropriate in geographic location, and provides appropriate care in a timely manner (Ibid). Acceptable/patient centred care accounts for the preferences of individuals, as well as the culture of their communities (Ibid). Equitable care is care which does not discriminate quality of care between individuals or communities, and safe refers to minimizing harm to users of the service (Ibid). This framework will be utilised in an analysis of abortion services in Banke in Chapter 7.

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3.5 Connecting the Themes

Figure 1 illustrates the relationship shown by the literature on how the societal norms of gender, marriage and childbearing, and sexuality are assumed to interact to create stigma around abortion. This stigma, as well as the legality and accessibility of abortion provision services, will effect a woman's decision making process surrounding abortion and the ways in which she is perceived to use her agency.

The theoretical frame work presented in this chapter provides the theoretical starting point from which the various findings can be understood and contextualised in later chapters.

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3.6 Research Question and Sub-Questions

After reviewing the existing literature and establishing a theoretical framework, I designed a main research question to address the knowledge gap surrounding societal perception of abortion in Nepal, and three sub-questions to help ensure a nuanced understanding of the research, and support the primary research question. They are as follows.

Main Research Question:

How are abortion services and societal norms and surrounding gender, marriage, and childbearing perceived to influence the agency of women in Banke District, Nepal, to seek abortion services?

Sub-Questions:

1.What are the norms for ideal childbearing, marriage, and gender relations in Banke District, Nepal?

2. In what ways does the circumstances of the pregnancy impact community perceptions of abortion in Banke District, Nepal?

3. How are abortion provision services perceived to enable, or discourage, women's agency to seek an abortion in Banke District, Nepal?

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Chapter 4: Study Methodology

4.1 Epistemological Stance

This research engages with the social norms that contribute to the creation of community perceptions of women who seek abortions, and is thus focused on how a particular social reality is created and is manifested, as opposed to seeking a concrete truth. My epistemological stance is inductive, as I had not drawn any conclusions prior to fieldwork data collection, and the research has drawn conclusions based on observations and research done in the field. For this reason, the epistemic stance that is most fitting to the research is best classified as interpretivism. This is defined by Snape and Spencer (2003) in their article on the foundations of qualitative research, as a stance in which “...the world is not governed by law-like regularities but is mediated through meaning and human agency; consequently the social researcher is concerned to explore and understand the social world using both the participant's and the researcher's understanding” (Page 17). As my research surrounds perceptions, it fundamentally focuses on a social creation of collective community meanings and various perceived ways of exercising agency and its repercussions within that meaning. The most accurate ontological stance to describe this research is subtle idealism, which is defined by Snape and Spencer (2003) as “...reality is only knowable by through socially constructed meanings....[and that] meanings are shared and there is a collective or objective mind” (Page 16). My research focuses on these collective meanings in a community, and that these collective meanings are constructed as opposed to absolute in nature.

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4.2 Research Location

The research occurred primarily in the city of Nepalgunj, with visits to communities just outside of Nepalgunj, in Banke District, Nepal. Banke is a district in the Mid-Western Region of Nepal, on the border of India, and is part of the Terai, or plains zone. Banke is a tropical, agricultural district, with a largely rural population that is engaged in agriculture (Government of Nepal 2011). Banke is connected to Kathmandu through Nepalgunj airport. Local transportation is mostly on unpaved, gravel and seasonal roads, by means of bus, auto-rickshaw (motorised rickshaws), and motorcycle. Nepalgunj is the biggest city in Banke, and has a variety of government and private medical services available for reproductive health issues.

Nepalgunj is located 7km from the border with India, where there is substantial cross-border traffic. Citizens of Nepal do not need visas to enter India (the reverse is also true). This facilitates extensive cross-border traffic and relationships, especially since many families live partially in India and partially in Nepal.

The last Nepalese census occurred in 2011, and thus provides the most recent numbers for the population statistics. The population of Banke at the last census was 491 313, with a 2016 projected population of 554 630 (Government of Nepal, 2011). The population of Banke is majority Hindu, with

Figure 2: Location of Banke District in Nepal

https://en.wikipedia.org/wiki/Banke_Distri ct

Figure 3: Map of Banke District, Nepal

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small minority Christian and Buddhist communities, however Nepalgunj does have a sizable Muslim population compared to the rest of Nepal (Ibid).In the Mid-Western Terai (specific numbers for Banke were not available), the literacy rate varied accross genders and age ranges. Men are more literate on average, with 83% of men literate compared to 66.3% of women (Ibid). Within this, there is disparity among age ranges, with both young men and young women having the highest levels of literacy, and literacy rates dropping steadily as the age range increases (Ibid). The main languages used in Banke are Nepali, Adawdhi, Tharu, and the rest is a mixture of Urdu, Magar, Hindi, and local dialects (Government of Nepal, 2014).

Banke also has a substantial population of ethnic Madhesi. Madhesi peoples originate from Northern India, but have lived in the terai of Nepal for many generations, while maintaining strong contacts with the broader Madhesi communities in Northern India. Madhesi peoples are not one cohesive ethnic group, they are of varied religions (majority Hindu or Muslim), and do not have a single shared language. However, Madhesi's share a specific type of marriage practice specific to Madhesi's (which will be explained in Box 1). Madhesi's are citizens of Nepal and are legally recognized as such by the government, but are still discriminated against and treated as different by the local communities in the terai, who consider them not to be Nepali. This has been a source of conflict in recent years, with Madhesi's organising protests in order to gain greater representation.

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4.3 Study Populations

As the research itself was conducted with the goal of understanding the community perceptions of women who seek abortions, the unit of analysis is women and girls who have to make decisions surrounding abortion services. Given that it is perceptions that are being examined, a variety of society members are consulted, but all in regard specifically to women and girls that are accessing abortions. Similarly, abortion service providers and religious leaders gave their perceptions of issues surrounding this topic. Therefore community members, health care professionals, and religious leaders, will be units of analysis as well, as they are used to examine the primary unit of analysis, which is women and girls who are making decisions regarding an abortion.

4.4 Sampling Strategy

Young peoples were found through the assistance of CWIN, a local NGO who I was connected with through the field supervisor of my colleagues, and helped to facilitate our entry to the field. Participants (for focus group discussions (FGD) and interviews) were chosen from Shree Secondary School, a public government school which CWIN facilitated contact with, and allowed me access to their students. Sampling was done from Shree Secondary school as my initial research question focused specifically on women under the age of 18 seeking abortions, which required a younger sample. Sampling was done based on age range and marital status. Participants (of FGDs of unmarried youth) were selected from classes 8-10 (as these were the older students more likely to know of the issues being discussed), with assistance from school administration in accessing the classrooms and identifying unmarried students. Married youth were specifically chosen for their marital status, and were selected with the assistance of the school staff and administration based upon their marital status. Given the low number of married students, all those who were married were interviewed. Out of school youth participants were determined with assistance from the Muslim Samaj in the communities visited. In Lumbini District, FGD participants were found through the NGO Care Nepal (whom I reached out to over email weeks earlier and agreed to help), who selected participants based on respondents participation in the Tipping Point programme run by Care. However, in the course of my fieldwork, my research question shifted as I realised my initial question was not feasible, requiring sampling from a broader range of community members as well as youth.

Abortion service providers were specially chosen for their profession, and were located through the Muslim Samaj, an NGO I was introduced to through my field supervisor, that worked specifically

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in the Muslim communities around Banke to promote development and SRH. All abortion service providers worked in rural health posts located in three different Village Development Communities (VDCs), which I went to to in order to conduct interviews with the relevant staff at the health post. Attempts were made to contact and interview abortion service providers at government hospitals, however government hospital staff refused to be interviewed.

Religious leaders in the community were specifically chosen for their roles. All religions leaders were contacted through connections my interpreter had in the community, and specific appointments made. The three Hindu Brahmins were selected from the main temples (Bageshwori and Gausala Temples) in Nepalgunj, and the three Mullahs selected from prominent positions in both local mosques and madrasas (local schools for Muslim students that teach the Quran in addition to regular schooling). This selection was purposeful as, given their prominent positions in their respective religions, it is assumed that they represent the dominant views and have opinions that are seen to have more influence in the communities.

Research participants sampled were a mixture of religions, genders, and ethnic groups. Madhesi individuals accounted for roughly half of those sampled (see section 4.2 for explanation of Madhesi). In regards to socio-economic status, the rural VDC's visited were poorer communities. Shree Secondary School, being a government school, mostly consisted of students from more impoverished backgrounds, as families with the means to will send their children to private schools, which are perceived to provide a better education.

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Box 1: Shree Secondary School

Shree Secondary School is a government run school on the North side of Nepalgunj. It has grades 1-10 (full Nepali range), as well as a special needs class for deaf students. The school has three main buildings for classrooms and offices, another building for an outhouse, and a large dusty field dotted with trees at the edges between the building on which the children can play. The students wear uniforms of light blue button dress shirts and navy pants for boys, and a light blue tunic and navy pants for girls. The school has a mix of religions and students, with many Madhesi students, some of whom have married.

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4.5 Data Collection Methods and Tools

The primary data collection methods utilized in this research is a mixed methods ethnography. Many of the findings are drawn from everyday interactions between myself and members of the community, in addition to various interactions that were observed between community members. Many of these interactions would happen with I would take walks down the main street of Nepalgunj, and talk to shopkeepers at their open store fronts. However, it was not possible to sit and have extended conversations, as my presence tended to draw a crowd, which made me uncomfortable. Many other informal conversations occurred with the staff at the hotel in which I stayed, as well as with my interpreters, and some of their social circles to which I was introduced. I also had many informal conversations in between field excursions for more formal methods. These while in the field with the staff members of the Muslim Samaj, school administrators while at Shree Secondary, and CWIN staff members on a variety of occasions. I was careful to extensively document these informal interactions and observations through use of extensive note taking in my research journal.

I observed several NGO run empowerment groups, three by CWIN and one by the Muslim Samaj. I chose to observe the empowerment groups as they dealt with issues of gender norms and roles, as well as SRH issues, which was relevant to my research. Two of the empowerment groups were run by CWIN as a three day course at Shree Secondary School. One of these was reserved for boys in classes 7-10, the other for girls in classes 7-10. Another of the empowerment groups was run by CWIN, twice daily, in the impoverished Dalit (low-caste, low social standing) community of Lagdhwa in Nepalgunj. These three empowerment groups focused on a variety of topics including planning life goals, making healthy life choices, body changes and puberty, promoting equality between genders, and healthy eating habits. The empowerment group run by the Muslim Samaj occurred daily at a home in Hirmaniya VDC and consisted of teenage girls, and focused on many of the same topics, but with additional focus on SRH issues, including HIV/AIDS and contraception.

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In addition to the ethnographic methods of data collection I utilized FGDs and in-depth interviews. I conducted seven FGDs and had in-depth interviews with 21 individuals. I chose to utilise FGDs in my research as they would allow me to see group dynamics around sensitive topics, and help to gauge an interpersonal reaction among the youth on how acceptable it was to talk about these issues socially. The FGDs occurred on various dates, in different locations. Some of the FGDs were well planned in advance and recorded, while others occurred from opportunities that arose in rural field excursions, such as being introduced to a pre-existing empowerment group whose participants agreed to talk with me. I used an interpreter, Sandhya Singh (fully introduced in section 4.5.3), for all FGDs and in-depth interviews. The FGDs often started off quietly and slowly since the participants (especially female) were often very shy, and would react to what I was asking or saying, as opposed to engaging in a conversation that built off of group comments. In order to overcome this challenge, extra time was given to the FGDs, to allow participants to become more comfortable and share more of their thoughts with the group. This did not always work, especially in the groups consisting of younger participants, but did help in many cases. In the case of one FGD with five teenage girls at Shree Secondary School, I provided paper and pens and they drew a cartoon of a girl in their community, which we used as as a starting point for the discussion. In order to supplement the community dynamic

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explored in FGDs, and to help to offset the reluctance of many individuals to share in a group setting. I utilised in-depth interviews, to gather individual opinions that might not be able to be shared as easily in a more social atmosphere. The in-depth interviews were all planned ahead of time.

All interviews and FGDs were conducted in a private space to ensure privacy for participants, and were provided with light refreshments. All participants were told of the general purpose of the research, and that their answers would be used in my Masters thesis, and ensured that their names or identity would not be revealed in the writing process through use of a pseudonym, before providing their consent to be interviewed. Additional consent was acquired in order to record the FGDs and interviews, all except one participant consented to being recorded. In the instance where the interviewee consented to be interviewed, but not recorded, extensive note taking was used to record the content of their responses. All FGDs and interviews used a general topic guide (which would change depending upon the direction of the conversation), but utilised a slower lead up of more general questions before questions about abortion, as many groups and individuals seemed reluctant to talk about it. The themes discussed varied between interviewees and FGDs depending on their responses to various questions, but consistent theme was to begin with icebreakers, and then moving into more general questions surrounding gender roles and childbearing norms, before moving on to more difficult topics such as abortion service knowledge and access, views on abortion, and consequences for women who have been found by their communities to have had abortions.

The final method that I utilised in this research was the examination of the medical records of 92 individuals who had had abortions at the Hirmaniya and Raniyapur VDC health posts. These records were from the health post's “Safe Abortion Books”, which were shown to me to view by health posts staff, who allowed me to take pictures of the data to use in my thesis. These books included women's name, age, date of abortion, gestation period at time of abortion, and details about any complications that may have occurred. Names and personal details of individuals have been omitted from these records to preserve anonymity.

In addition to research that I undertook, I used additional data gathered by Rory Bowe, a fellow researcher within the Her Choice project also studying at the University of Amsterdam who was conducting research into child grooms. He provided me with parts of several of his transcripts that related to my research topics. I did much of my research in tandem with Mr. Bowe, and we were able to share our various findings, as well as act as a check upon the others research to ensure consistency and accuracy in the findings.

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Table 1: Data Gathering and Participant Demographics METHOD USED RESPONDENT TYPE RESPONDENT NUMBERS

GENDER AGE MARITAL

STATUS

RELIGION

In-Depth Interviews

Young People 7 2 Male, 5 Female

14-22 All Married 1 Buddhist, 2 Hindu, 3 Muslim Abortion Service

Providers 6 1 Male, 5 Female Not Asked. Not Asked. 1 Hindu, 5 Muslim

Religious Leaders 6 All Male Not Asked. Not Asked. 3 Hindu, 3 Muslim

Focus Group Discussion

Young Men in School

6, in 1 FGD All Male 16-19 All Unmarried All Hindu

Young Men out of

School 26, in 2 FGD All Male 11-27 6 Unmarried, 4 Married All Muslim Young Women in

School 15, in 3 FGD All Female 13-18 All Unmarried 13 Hindu, 2 Muslim

Young Women out

of School 12, in 1 FGD All Female 13-20 5 Married, 7 Unmarried All Muslim

Informal ‘Chats’

Interpreters 3 1 Male, 2

Female 20-23 All Unmarried All Hindu NGO Staff 8 5 Male, 3

Female Not Asked. Not Asked. Not Asked. Community

Members 9 5 Male, 4 Female from Varied approx. 20 to 40’s

3 Married, 6

Unmarried All Hindu

Observation Youth Groups 6 Groups, Unknown

Numbers. 4 NGO Sessions, 2 Youth Groups

Unknown

Numbers. Unknown Exactly, range from 11 to approx. 25 Exact Numbers Unknown, Most Unmarried Unknown.

Public Events 1 Police Public Event on Child Marriage

Unknown. Unknown. Unknown. Unknown.

Abortion Medical Records

Hirmaniya 69 All Female 20-36 Unknown Unknown. Raniyapur 23 All Female 18-45 Unknown. Unknown.

Stigma and secrecy in Banke District, Nepal : how socieatal views are perceived to influence women's agency on accessing abortions

Claire Thomson